South Africa field epidemiology training program: developing and building applied epidemiology capacity, 2007-2016

Approaches, challenges, and opportunities to strengthen the epidemic intelligence workforce: a scoping review

BACKGROUND

Weak surveillance systems have limited countries' ability to adequately respond to public health emergencies. Strengthening the human workforce in this field is considered an important opportunity to ensure the future response to infectious diseases outbreaks globally. A scoping review of the academic literature and relevant documents was conducted to identify approaches, challenges, and opportunities to strengthen the epidemic intelligence (EI) workforce.

METHODS

Five peer-reviewed databases were systematically searched, as well as Google as a grey literature source. English language articles and documents published between 2014 and 2022 were included. No geographical restrictions were set.

RESULTS

37 articles and 20 documents were included in the review. Professional training, the acknowledgement of including a broad variety of disciplines into the workforce, the inclusion of communities, the pursuit of a One Health approach and the use of digital tools were identified as impeding and/or facilitating the EI workforce. The review shows that the field epidemiology training programme is a prominent approach for strengthening the EI workforce and that little evidence exists on how non-traditional disciplines (e.g., disciplines besides medicine, laboratory science, or epidemiology) contributing to surveillance may support the future EI workforce.

CONCLUSION

The identification of approaches, challenges, and opportunities of EI can inform future policy and practice on strengthening the EI workforce. The conduct of more high-quality studies is needed to guide this process. The potential benefits of integrating a wider range of disciplines than currently found in the surveillance workforce and of involving communities in disease surveillance needs to be further researched.

Evaluation of Ethiopia's field epidemiology training program - frontline: perspectives of implementing partners

BACKGROUND

Field Epidemiology Training Program (FETP) has been adopted as an epidemiology and response capacity building strategy worldwide. FETP-Frontline was introduced in Ethiopia in 2017 as a three-month in-service training. In this study, we evaluated implementing partners' perspectives with the aim of understanding program effectiveness and identifying challenges and recommendations for improvement.

METHODS

A qualitative cross-sectional design was utilized to evaluate Ethiopia's FETP-Frontline. Using a descriptive phenomenological approach, qualitative data were collected from FETP-Frontline implementing partners, including regional, zonal, and district health offices across Ethiopia. We collected data through in-person key informant interviews, using semi-structured questionnaires. Thematic analysis was conducted, assisted with MAXQDA, while ensuring interrater reliability by using the consistent application of theme categorization. The major themes that emerged were program effectiveness, knowledge and skills differences between trained and untrained officers, program challenges, and recommended actions for improvement. Ethical approval was obtained from the Ethiopian Public Health Institute. Informed written consent was obtained from all participants, and confidentiality of the data was maintained throughout.

RESULTS

A total of 41 interviews were conducted with key informants from FETP-Frontline implementing partners. The regional and zonal level experts and mentors had a Master of Public Health (MPH), whereas district health managers were Bachelor of Science (BSc) holders. Majority of the respondents reflected a positive perception towards FETP-Frontline. Regional and zonal officers as well as mentors mentioned that there were observable performance differences between trained and untrained district surveillance officers. They also identified various challenges including lack of resources for transportation, budget constraints for field projects, inadequate mentorship, high staff turnover, limited number of staff at the district level, lack of continued support from stakeholders, and the need for refresher training for FETP-Frontline graduates.

CONCLUSIONS

Implementing partners reflected a positive perception towards FETP-Frontline in Ethiopia. In addition to scaling-up the program to reach all districts to achieve the International Health Regulation 2005 goals, the program also needs to consider addressing immediate challenges, primarily lack of resources and poor mentorship. Continued monitoring of the program, refresher training, and career path development could improve retention of the trained workforce.

A comparative cross-sectional evaluation of the Field Epidemiology Training Program-Frontline in Ethiopia

Background

The Field Epidemiology Training Program (FETP)-Frontline is a three-month in-service training aimed at improving surveillance officers’ capacity to collect, analyze, and interpret surveillance data, and respond to health emergencies. We evaluated the effectiveness of the FETP-Frontline which was introduced in Ethiopia in 2016.

Methods

We conducted a comparative, randomized cross-sectional study to assess surveillance-related knowledge, skills, and performance among trained and untrained officers using a structured questionnaire and observation checklist. We compared the knowledge, skills, and performance scores of trained and untrained officers using the Fisher’s Exact test, chi-square test, and t-test at p-value < 0.05 for statistical significance.

Results

We conducted the study among 74 trained and 76 untrained surveillance officers. About three-quarters of all participants were male, and the average age was 34 (± 8.6) years. Completeness and timeliness of surveillance reports were significantly higher among trained than untrained surveillance officers. The trained officers were more likely to have produced epidemiologic bulletins (55% vs 33%), conducted active surveillance six months before the survey (88% vs 72%), provided surveillance training (88% vs 65%), conducted strengths, weakness, opportunities, and threats (SWOT) analysis (55% vs 17%), and utilized Microsoft Excel to manage surveillance data (87% vs 47%). We also observed improved surveillance officers’ perceived skills and knowledge, and the availability and quality of surveillance formats and reports among the trained group.

Conclusions

FETP-Frontline trained surveillance officers demonstrated better knowledge, skills, and performance in most surveillance activities compared to the untrained officers. FETP-Frontline can address competency gaps among district surveillance officers in Ethiopia and other countries. Scaling up the program to cover unreached districts can enable achieving the human resource development core capacity requirement of the International Health Regulations 2005.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-13326-2.

A national HIV clinical mentorship program: Enabling Zambia to accelerate control of the HIV epidemic

Although Zambia has increased the proportion of people living with HIV (PLHIV) who are on antiretroviral therapy (ART) in recent years, progress toward HIV epidemic control remains inconsistent. Some districts are still failing to meet the UNAIDS 90/90/90 targets where 90% of PLHIV should know their status, 90% of those diagnosed should be on ART, and 90% of those on ART should achieve viral load suppression (VLS) by 2020. Providing consistently excellent HIV services at all ART health facilities is critical for achieving the UNAIDS 90/90/90 targets and controlling the HIV epidemic in Zambia. Zambia Ministry of Health, in collaboration with the U.S. Centers for Disease Control and Prevention (CDC), aimed to achieve these targets through establishing a national HIV clinical mentorship program in which government-employed mentors were assigned to specific facilities with a mandate to identify and ameliorate programmatic challenges. Mentors were hired, trained and deployed to individual facilities in four provinces to mentor staff on quality HIV clinical and program management. The pre-mentorship period was July 2018-September 2018 and the post-mentorship period was July 2019-September 2019. Review of key programmatic indicators from the pre and post-deployment periods revealed the proportion of people who had a positive HIV test result out of those tested increased from 4.2% to 6.8% (P <0.001) as fewer HIV tests were needed despite the number of PLHIV being identified and placed on ART increasing from 492,613 to 521,775, and VLS increased from 84.8% to 90.1% (p <0.001). Key considerations in the establishment of an HIV clinical mentorship program include having a government-led process of regular site level data review and continuous clinical mentorship underpinned by quality improvement methodology.

Innovations to maximise impact of a data for decision-making training programme in the Federated States of Micronesia

Accurate and timely health information is an essential foundation for strengthening health systems. Data for decision making (DDM) is a training curriculum designed to enhance capacity of health department staff to capture and use high-quality data to address priority health issues. In 2013, the Pacific Public Health Surveillance Network adapted and piloted the DDM curriculum as an 'at work, from work, for work' field epidemiology training programme component for low-income and middle-income Pacific Island jurisdictions. Based on lessons learned from the pilot, we made several innovations, including delivery on-site at each district (rather than bringing trainees to a central location), conducting pre-DDM consultations and ongoing contact with health leaders across the programme, taking more care in selecting trainees and enrolling a larger cohort of students from within each health department. The decentralised programme was delivered in-country at four sites (both at national and state levels) in the Federated States of Micronesia. Following delivery, we performed an external evaluation of the programme to assess student outcomes, benefits to the health department and general programme effectiveness. Of the 48 trainees who completed all four classroom modules, 40 trainees participated in the evaluation. Thirty-two of these trainees completed the programme's capstone field project. Eighteen of these projects directly contributed to changes in legislation, revised programme budgets, changes in programme strategy to augment outreach and to target disease and risk factor 'hot spots'.

Prevalence of diarrhoeal pathogens among children under five years of age with and without diarrhoea in Guinea-Bissau

BACKGROUND

Childhood diarrhoea, a major cause of morbidity and mortality in low-income regions, remains scarcely studied in many countries, such as Guinea-Bissau. Stool sample drying enables later qPCR analyses of pathogens without concern about electricity shortages.

METHODS

Dried stool samples of children under five years treated at the Bandim Health Centre in Bissau, Guinea-Bissau were screened by qPCR for nine enteric bacteria, five viruses, and four parasites. The findings of children having and not having diarrhoea were compared in age groups 0-11 and 12-59 months.

RESULTS

Of the 429 children- 228 with and 201 without diarrhoea- 96.9% and 93.5% had bacterial, 62.7% and 44.3% viral, and 52.6% and 48.3% parasitic pathogen findings, respectively. Enteroaggregarive Escherichia coli (EAEC; 60.5% versus 66.7%), enteropathogenic E. coli (EPEC; 61.4% versus 62.7%), Campylobacter (53.2% versus 51.8%), and enterotoxigenic E. coli (ETEC; 54.4% versus 44.3%) were the most common bacterial pathogens. Diarrhoea was associated with enteroinvasive E. coli (EIEC)/Shigella (63.3%), ETEC (54.4%), astrovirus (75.0%), norovirus GII (72.6%) and Cryptosporidium (71.2%). The only pathogen associated with severe diarrhoea was EIEC/Shigella (p<0.001). EAEC was found more frequent among the infants, and EIEC/Shigella, Giardia duodenalis and Dientamoeba fragilis among the older children.

CONCLUSIONS

Stool pathogens proved common among all the children regardless of them having diarrhoea or not.

The role of Namibia Field Epidemiology and Laboratory Training Programme in strengthening the public health workforce in Namibia, 2012-2019

Namibia faces a critical shortage of skilled public health workers to perform emergency response operations, preparedness activities and real-time surveillance. The Namibia Field Epidemiology and Laboratory Training Programme (NamFELTP) increases the number of skilled public health professionals and strengthens the public health system in Namibia. We describe the NamFELTP during its first 7 years, assess its impact on the public health workforce and provide recommendations to further strengthen the workforce. We reviewed disease outbreak investigations and response reports, field projects and epidemiological investigations conducted during 2012-2019. The data were analysed using descriptive methods such as frequencies and rates. Maps representing the geographical distribution of NamFELTP workforce were produced using QGIS software V.3.2. There were no formally trained field epidemiologists working in Namibia before the NamFELTP. In its 7 years of operation, the programme graduated 189 field epidemiologists, of which 28 have completed the Advanced FELTP. The graduates increased epidemiological capacity for surveillance and response in Namibia at the national and provincial levels, and enhanced epidemiologist-led outbreak responses on 35 occasions, including responses to outbreaks of human and zoonotic diseases. Trainees analysed data from 51 surveillance systems and completed 31 epidemiological studies. The NamFELTP improved outcomes in the Namibia's public health systems; including functional and robust public health surveillance systems that timely and effectively respond to public health emergencies. However, the current epidemiological capacity is insufficient and there is a need to continue training and mentorship to fill key leadership and strategic roles in the public health system.

COVID-19: Nothing is Normal in this Pandemic

This manuscript brings attention to inaccurate epidemiological concepts that emerged during the COVID-19 pandemic. In social media and scientific journals, some wrong references were given to a “normal epidemic curve” and also to a “log-normal curve/distribution”. For many years, textbooks and courses of reputable institutions and scientific journals have disseminated misleading concepts. For example, calling histogram to plots of epidemic curves or using epidemic data to introduce the concept of a Gaussian distribution, ignoring its temporal indexing. Although an epidemic curve may look like a Gaussian curve and be eventually modelled by a Gauss function, it is not a normal distribution or a log-normal, as some authors claim. A pandemic produces highly-complex data and to tackle it effectively statistical and mathematical modelling need to go beyond the “one-size-fits-all solution”. Classical textbooks need to be updated since pandemics happen and epidemiology needs to provide reliable information to policy recommendations and actions.

Strengthening Applied Epidemiology in West Africa: Progress, Gaps, and Advancing a Regional Strategy to Improve Health Security

The ability to prevent, promptly detect, and appropriately respond to a public health threat is essential for health security. Field epidemiology training has helped increase the quality and quantity of the public health workforce to strengthen disease surveillance, outbreak preparedness and response, and general public health capacity. We conducted a desk review on the status of the Field Epidemiology and Laboratory Training Program model in 16 countries in West Africa. We also developed a questionnaire and shared it with West African Health Organization (WAHO) member states to document their experiences and the status of training in their countries. WAHO organized a regional 3-day consultative meeting with major stakeholders in the region to examine progress, gaps, and challenges, and outline a roadmap to strengthen the Field Epidemiology and Laboratory Training Program. Stakeholders shared their experiences, engaged in discussions to identify strengths and gaps, and made plans on a way forward. Member states are at different levels of implementing field epidemiology and laboratory training programs in their countries, and, therefore, major gaps remain in the number and distribution of trained epidemiologists throughout West Africa. Member states implement different variants of the program and in some instances the same cadre of health workers are trained in different but comparable programs with different funding streams. Two member states had not begun implementing the training program. Developing regional centers of excellence was recommended in the long term while collaboration among member states to train the required number of epidemiologists to fill the acute needs could be helpful in the short and medium term. Curriculum harmonization and expansion, deployment and use of trained epidemiologists, accreditation of training institutions, and generation of indigenous funding streams are recommended to improve the Field Epidemiology and Laboratory Training Program in West Africa.

One Field Epidemiologist per 200,000 Population: Lessons Learned from Implementing a Global Public Health Workforce Target

The World Health Organization monitoring and evaluation framework for the International Health Regulations (IHR, 2005) describes the targets for the Joint External Evaluation (JEE) indicators. For workforce development, the JEE defines the optimal target for attaining and complying with the IHR (2005) as 1 trained field epidemiologist (or equivalent) per 200,000 population. We explain the derivation and use of the current field epidemiology workforce development target and identify the limitations and lessons learned in applying it to various countries' public health systems. This article also proposes a way forward for improvements and implementation of this workforce development target.